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BOX 31
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04122
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PUTNAM ODURN HEALTH DEPARDOU
�'W Y O4` r I OPOSAL FOR SBWAGE DISPOSAL SYSTEM REPAIR
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OWNER'S NAME J ?%i' F r- ( ER-, PHONE �'
SITE LOCATION 2f Y' LpQ-f, o y u e- TM -63,'J 3 YO
MAILING ADDRESS LA-P —E PF g *S t. o r
DATE
" PCEID Complaint #,
Name & Relationship U.e, owner,tenant, etc.) 2 S
TYPE FACILITY
PHONE Z&
REGISTRATION #
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal from licensed professional engineer or
registered architect.
Proposal approved Proposal Disapproved
Inspector's Signature & T
2 �;X�eca'
Da
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applica ebl .
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site.Street Name, Town and Tax Map number.
c. Location of installed ccmponents tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diem. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or reported agent of owner agree to the above conditions.
SIGNATURE TITLE Air DATE
PIES: White (PC D); YeUcw (Tam ED; Pink (AppLiamt)
D.` INSPECTION
Date Tnsnector,.
----------------- --------------------------------------
(1) Indicate location of SSTS
A. Size and type of septic tank ... gallons
e OConcrete Mastic
B. Type of absorption area
1. Fields - ft. I Pits - 3. Gallies . fl.
(2) Indicate " setbacks, front- street, backyard,. and side yard dimensions
(3) Show location of well
(4) Show location of driveway
(5) Note physical features (steep slopes, rock outcrops, streams/wetlands)
SECTION E. EXISTING WATER SUPPLY:-
OPWS ❑ well
..,�didual well
❑ Mug
Casing above ground
COMMENTS:. �0'�%e:�
PUTNA M COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
...1NITLAL:INDIVIDUAL ADDITION [REPAIR FORM...
SECTION A. GENERAL INFO TION r �!
Name of Project TM#
Year of Construction Size of Parcel
SECTION B. TOPOGRAPHY (Please check all appr priate boxes)
1. Offilly ORollini 13Steep slope en slope zq�
2. ®Evidence of wetlands 11ow areas subject to, flooding
.
Drainage ditches r outcrops
I Property lines evident?
4. Water courses exist on, or adjacent to parcel?
5. Existing individual wells within 200ft of the existing SSTS?
OFlat
Clodies of water
SECTION C. EXISTING SUBSURFACE SEWAGE TREATMENT SYSTEM (SSTS)
1. Physical character of existing SSTS area.
A. Clevel, UGentle slope 1�p slope
B. OWell drained lg well drained
ClSome what poorly drained ®Poorly drained
C. Area available for SSTS. (Primary & Reserve)
xemely � `f invited OSomewhat limited UAdequate ft x ft
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